Does the contribution of modifiable risk factors on oral health inequities differ by experience of negative life events among Indigenous Australian adults?

(1)

RESEARCH ARTICLE

Does the contribution of modifiable risk factors on oral health inequities differ by experience of negative life events among Indigenous Australian adults?

Lisa JamiesonID¹*, Joanne Hedges¹, Yin Paradies², Xiangqun JuID¹

1 Australian Research Centre for Population Oral Health, University of Adelaide, Adelaide, South Australia, Australia, 2 School of Human and Social Science, Faculty of Arts and Education, Deakin University, Melbourne, Australia

*[email protected]

Abstract

Objective

Although the prevalence of poor self-rated oral health and experience of negative life events among Indigenous adults is high, the contribution of modifiable risk factors is unknown. We aimed to estimate the contribution of modifiable risk factors in poor self-rated oral health among Indigenous Australian adults with high and low experience of negative life events using decomposition analysis.

Methods

The study utilised a cross-sectional design, with data from a large convenience study of Indigenous adults in South Australia. Participants were stratified based on a median split of negative life events in the last 12 months. The outcome was the proportion of fair/poor self- rated oral health (SROH). Independent variables included experience of racism, sex, age, geographic location, car ownership, and time since last dental visit.

Results

Of the 1011 participants, the proportion with fair poor self-rated oral health was 33.5% (95%

CI 30.5 to 36.4) and the proportion who had experienced 3+ negative life events in the past 12 months was 47.3% (95% CI 43.7 to 50.9). More than half the contribution in fair/poor self- rated oral health among Indigenous adults with a higher magnitude of negative life events was from experience of racism (55.3%, p<0.001), followed by residential location (19.9%), sex (9.7%) and car ownership (9.8%).

Conclusions

The contributions of modifiable risk factors in poor self-rated oral health among Indigenous adults with different exposures to negative life events differed substantially. Targets to reduce racism will decrease oral health inequities for both groups, however Indigenous a1111111111

a1111111111 a1111111111 a1111111111 a1111111111

OPEN ACCESS

Citation: Jamieson L, Hedges J, Paradies Y, Ju X (2023) Does the contribution of modifiable risk factors on oral health inequities differ by experience of negative life events among Indigenous Australian adults? PLoS ONE 18(6): e0286697.

https://doi.org/10.1371/journal.pone.0286697 Editor: Syed Afroz Keramat, The University of Queensland, AUSTRALIA

Received: February 22, 2023 Accepted: May 20, 2023 Published: June 8, 2023

Copyright:©2023 Jamieson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability Statement: Data cannot be shared publicly because of ethics stipulations. Data are available from the University of Adelaide Human Ethics Committee (contact +61 8 8313 4611) for researchers who meet the criteria for access to confidential data.

Funding: This study was funded by the Australia’s National Health and Medical Research Council (APP1120215). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

(2)

adults who have experienced substantial negative life events require additional focus on provision of culturally safe dental care.

Introduction

Indigenous Australians (those identifying as Aboriginal, Torres Strait Islander or both) experience greater inequities on almost every health and wellbeing indicator compared with non- Indigenous Australians [1]. There is a higher prevalence of non-communicable diseases, including type 2 diabetes, cardiovascular disease, chronic kidney disease and metabolic syn- drome [2]. Around three-quarters of Indigenous Australian adults are overweight or obese [3].

The social and emotional wellbeing impacts among Australia’s First Peoples are also high [4].

In 2018–19, around one-quarter of Indigenous Australians reported having a diagnosed mental health or behavioural condition and ‘high or very high’ levels of psychological distress [5].

For many Indigenous Australians, social and emotional wellbeing is a holistic construct encap- sulating a sense of belonging, positive interpersonal relationships, strong cultural identity and a belief that life has purpose and value [6]. Poor social and emotional wellbeing is affected by major stressors including removal from family, death of family or close friends, incarceration, unemployment, racial discrimination and everyday stressors that are exacerbated by social dis- advantage [4].

These inequities extend to oral health. In Australia’s 2017–18 National Survey of Adult Oral Health, 98 percent of Indigenous adults had one or more missing teeth [7], with earlier estimates suggesting that the prevalence of untreated dental decay among Indigenous adults was 57 percent, compared with 25 percent among non-Indigenous Australians [8]. A frequently cited reason for this inequity is lack of access to culturally-responsive dental providers, together with dental fear, experiences of racism and distrust towards dental health professionals [9].

While the risk factors impacting Indigenous oral health inequities have been identified, there has been no analysis of the difference in risks, and contribution of these differences, between Indigenous adults with high or low experience of negative life events. Nor has there been analysis enabling explicit percentages of risk contribution to be calculated. This is important for policy implications in the allocation of scarce resourcing in the dental public health setting, and for effective oral health promotion initiatives and that account for the broader social and emotional wellbeing environment in which Indigenous Australians live. This study therefore aimed to estimate the contribution of modifiable risk factors in poor self-rated oral health among Indigenous Australian adults with high and low experience of negative life events using decomposition analysis. The hypothesis is that the percentage contribution of each risk factor will differ for Indigenous adults with high experience of negative life events in comparison with their counterparts with low experience of negative life events.

Methods

Data was obtained from a large convenience sample (n = 1,011) of adults aged 18+ years who identified as Indigenous in South Australia between Feb 2018 and Jan 2020 as part of a broader study investigating HPV infection and oropharyngeal squamous cell carcinoma [10]. The study was governed by an Indigenous Reference Group, with data collected by trained Indige- nous research officers. Participants were primarily recruited through Aboriginal Community Controlled Health Organisations (ACCHOs), who were key study stakeholders. After having

Competing interests: The authors have declared that no competing interests exist.

(3)

the study explained and signing informed consent forms, participants were requested to com- plete a questionnaire (with assistance from study staff if required) that contained information on socio-demographic characteristics, health-related factors, experiences of racism, recent his- tory of negative life events and self-rated oral health.

Ethical approval

Ethical approval was received from the University of Adelaide Human Research Ethics Com- mittee (H-2016-246) and the Aboriginal Health Council of South Australia’s Human Research Ethics Committee (04-17-729). All participants provided written, informed consent.

Variables

Outcome variable. Self-rated oral health was asked by the question; ‘Would you rate your oral health as’, with response options dichotomised into ‘fair or poor’ and ‘good, very good or excellent’.

Exposure variable. Negative life events were captured using a modified form of the Nega- tive Life Events Scale [11]. The specific question asked ‘In the last 12 months, have you or anyone in your family experienced any of the following: ‘incarceration’, ‘domestic violence’,

‘death’, ‘drug/alcohol misuse’, ‘child removal’, ‘psychological distress’ and ‘cultural or spiritual pain’. Response options were ‘yes’ or ‘no’. The median number of negative life events was two, with this variable then dichotomised into ‘�2’ and ‘3+’ negative life events in last 12 months.

Covariates

Experience of racism was assessed using the Measure of Indigenous Racism Experiences (MIRE) [12], which assesses experiences of inter-personal racism across 9 mutually exclusive settings in the last 12 months. The question was: ‘In the last 12 months, have you felt that you have been treated unfairly in any of the following ways because of your racial or ethnic background’? The items evaluate experiences of racism across a range of settings, such as the labour market, housing, health services and education sector. Responses were recorded on a 5-point Likert scale and dichotomized into ‘strongly disagree, disagree, neither agree nor disagree’ and

‘agree and strongly agree’. A participant was considered to have experienced racism if he/she reported being treated unfairly because of their racial or ethnic background in at least one of the 9 settings.

Demographic characteristics included age (<37 years or 37+ years), sex (male or female) and geographic location (metropolitan or non-metropolitan).

Socioeconomic characteristics was measured using car ownership from question ‘Do you own a car?’ and two responses (Yes or No).

Dental behaviour was measured using time since last dental visit and dichotomised into

‘less than one year ago’ or ‘more than one year ago’.

Statistical analysis

Descriptive analyses were conducted to examine the distribution of socio-demographic, dental behaviour, experience of racism and negative life events, and the proportion of fair/poor self- rated oral health. Statistically significant differences were denoted by 95% confidence intervals (CI) that did not overlap.

Blind-Oaxaca decomposition analysis was used to evaluate the contribution of demographic (age, sex and geographic location), socioeconomic (car ownership), dental behaviours (last dental visit) and experience of racism (MIRE) factors to changes in oral health

(4)

(proportion of fair/poor self-rated oral health) between experience of negative life events groups (‘�2’ and ‘3+’). Blind-Oaxaca decomposition analysis is used to calculate the difference in an outcome between two groups by respective differences in the distributions of selected independent variables [13]. All analyses were conducted using thedecompose & oaxacacom- mand in Stata 17.

Results

Table 1shows sample characteristics and cross-tabulations by proportion of fair/poor self- rated oral health. A higher proportion of participants were aged 37 years and above (52%), were female (over 66%), resided in non-metropolitan locations (63%), owned a car (55%), and last visited a dentist greater than 12 months ago (54%). Over half the participants (52%) experienced racism in one or more settings in the last 12 months and almost half (47%) experienced 3 or more negative life events in the last 12 months. The proportion of fair/poor self-rated oral health was 34%. The proportion of fair/poor SROH was higher among older age groups (40%), those who visited a dentist over a year ago (38%) and those who had experienced racism in the last 12 months (39%).

The distribution of negative life events in the last 12 months is shown inTable 2. Over 85 percent of participants had experienced one or more negative life events. Almost two-thirds (65%) had experienced death of a close friend or family member. Over half (56%) had experienced psychological distress and 43% had experienced drug and/or alcohol misuse. Around one-fifth (19.7%) of participants had experienced one negative life event in the last 12 months, 15% had experienced two and 14% had experienced three. Almost two-thirds (64%) of

Table 1. Sample characteristics and proportion of fair/poor self-rated oral health (SROH) among Indigenous Australian adults (n = 1011).

% (95% CI) Proportion fair/poor oral health (95% CI)

Total 33.5 (30.5–36.4)

Age group (Years)

�37 52.2 (49.1–55.3) 39.6 (35.4–43.9)

<37 47.8 (44.7–50.9) 26.7 (22.7–30.8)

Sex

Male 33.6 (30.7–36.5) 31.6 (26.7–36.6)

Female 66.4 (63.5–69.3) 34.4 (30.7–38.1)

Geographic location

Non-Metropolitan 62.7 (59.7–65.7) 32.6 (28.9–36.3)

Metropolitan 37.3 (34.3–40.3) 35.1 (30.2–40.0)

Car ownership

No 44.6 (41.5–47.6) 34.0 (29.6–38.5)

Yes 55.4 (52.4–58.5) 33.0 (29.1–37.0)

Last dental visiting

More than one year ago 53.7 (50.6–56.8) 37.5 (33.4–41.6) Less than one year ago 46.3 (43.2–49.4) 28.9 (24.7–33.1) Measure of Indigenous racism experiences

Yes 51.9 (48.8–55.0) 38.5 (34.2–42.7)

No 48.1 (45.0–51.2) 28.1 (24.0–32.2)

Negative life events in the last 12 months

3+ 47.3 (43.7–50.9) 36.2 (31.1–41.3)

�2 52.7 (49.1–56.3) 33.9 (29.1–38.6)

https://doi.org/10.1371/journal.pone.0286697.t001

(5)

participants had experienced 3 or more negative life events, and almost one-quarter (23.3%) had experienced 5 or more negative life events in the last 12 months.

The distribution of experience of racism in the last 12 months is shown inTable 3. Nearly one-third (31.6%) had experienced racism in law enforcement, 22% had experienced racism in government service provision and almost one-fifth (18.8%) had experienced racism in employment. Around 16% had one experience of racism in the last 12 months, 9% had two experiences and 7% had three experiences. Just over one-fifth (20.1%) had four or more experiences of racism in the last 12 months.

The decomposition of negative life events changes (from 2 or less to 3 or more in the last 12 months) in proportion of fair/poor self-rated oral health shows that approximately 85% of the increase was explained by the change in sociodemographic characteristics, and experience of racism (Table 4). More than half the contribution was from experience of racism (55%), followed by residential location (nearly 20%), car ownership and sex (approximately 10 percent each).

Discussion

This study tested the hypothesis that the contribution of socio-demographic, economic and behavioural risk factors on fair/poor self-rated oral health would differ for Indigenous adults with high experience of negative life events in comparison with their counterparts with low experience of negative life events. The hypothesis proved to be true, with racism being the risk factor with the most overwhelming contribution. The findings have important policy transla- tion implications, as they indicate that while targets to reduce structural and personal racism, in its various guises, will reduce oral health inequities for all Indigenous Australians, an additional focus is particularly required for Australia’s First Peoples with recent experience of negative life events (with direct implications on social and emotional wellbeing).

Table 2. Distribution of responses to the negative life events scale*among Indigenous Australian adults (n = 1011).

% Cumulative %

1: Incarceration 27.5

2: Domestic violence 30.4

3: Death 65.0

4: Drug/alcohol abuse 42.5

5: Child removal 17.3

6: Psychological distress (depression/anxiety) 55.7

7: Cultural/spiritual pain 33.6

8: Other 22.9

No negative life event 15.3 15.3

1 negative life event 19.7 35.2

2 negative life events 15.0 50.2

*The question asked was: ‘In the last 12 months please tick if you or anyone else in your family has experienced any following: (response options above)’

(6)

It is important to highlight the overwhelmingly high proportion of both racism (52%) and negative life events (3+, 47%) experienced by Indigenous participants in our study. Markwick and colleagues, in a population health survey in Victoria, Australia, estimated that 17% of their Indigenous participants experienced at least one episode of racism the previous year compared with 5% of non-Indigenous participants [15]. In research involving 1,033 Indigenous Austra- lians, 38% reported being treated unfairly because of their Indigenous background, 44%

reported hearing racial slurs in the workplace, and 59% reported receiving comments about the way they look or ‘should’ look as an Indigenous person. Just over one-quarter (28%) reported working in "culturally unsafe workplaces" [16]. Our estimates are far higher than those reported in these recent surveys. To the best of our knowledge, there are no estimates of negative life events at a population level for Indigenous Australians. However, in the 2014–15 National Aboriginal and Torres Strait Islander Social Survey, 22% of participants had experienced physical violence in the last 12 months, with 8 percent experiencing physical violence on more than one occasion [5]. Fifteen percent had been arrested in the last five years and 9 percent had been incarcerated in their lifetime.

Just over one-third of participants self-rated their oral health as fair or poor, compared with 24 percent reported in the 2017–18 National Survey of Adult Oral Health [17]. The self-rated oral health estimates were more favourable than other populations involving Indigenous Aus- tralians. For example, in a convenience sample of Indigenous adults from the Northern Terri- tory, the proportion of fair/poor self-rated oral health was 52%, and among a cohort of women pregnant with an Aboriginal child in South Australia, the proportion of fair/poor self-rated oral health was 54 percent [18].

Table 3. Distribution of responses to the Measure of Indigenous Racism Experiences scale*among Indigenous Australian adults (n = 1011).

Where racism was experienced: % Cumulative %

1: Employment 18.8 18.8

2: Domestic 14.1 32.9

3: Educational/academic 17.1 50.0

4: Recreational/leisure 15.7 65.7

5: Law (enforcement) 31.6 97.3

6: Health care 17.6 114.9

7: Government service provision 22.0 136.9

8: Public settings 17.2 154.1

9: Other 24.6 178.7

No experience of racism 48.1 48.1

1 experience of racism 16.3 64.4

2 experiences of racism 8.5 72.9

*The question asked was: ‘In the last 12 months, have you felt that you have been treated unfairly in any of the following ways because of your identity as an Aboriginal and/or Torres Strait Islander person’? (response options above)’

(7)

In recent years, there has been concerted efforts from dental professional and governance bodies to name and address racism in the dental sector in Australia. This includes in dental public health settings [19], research projects [20], funding agencies [21] and regulatory author- ities including the Australian Health Practitioner Health Regulation Agency [22]. Internation- ally, there has been substantial effort to increase the profile of anti-racist frameworks in dental school curricula [23], with this movement also obtaining momentum in Australian dental schools.

Our findings emphasize the inherent uniqueness of the social composition and life experiences of many Indigenous Australians that makes Indigenous Australians so much more vul- nerable to downstream consequences including poor oral health than their non-Indigenous peers. This is distinct from differences in social advantage alone. It is telling that experience of racism was the determinant having the most impact on the outcome (55%), with the effect of geographic location also being substantial (20%). However, whilst policies to reduce racism are increasing in their scope and remit across a multitude of services, and the challenges with regional and remote dwelling are increasingly recognised by government agencies, the sheer magnitude of negative life events experienced by many Indigenous Australians is a difficult challenge to address. This is, in large part, because of the layering of oppressions experienced by many Indigenous Australians, and the intersections, complexities and early age of onset of these commencing, that continue (and multiply) across the life course.

Study limitations include the design being cross-sectional, meaning no causal inferences can be implied. In addition, because a convenience sample was used some bias sources to com- pose the study population were not controlled. Specifically, the magnitude of outcomes and exposures, and the risks of over/underestimation including the consequences to associations

Table 4. Decomposition of the change in the proportion of fair/poor self-rated oral health (SROH) among Indigenous Australian adults.

Proportion of SROH (negative life events 3+) 36.2%

Proportion of SROH (negative life events�2) 33.9%

Due to endowments (E) 0.025

Due to coefficients (C) 0.016

Due to interaction (CE) -0.011

Explained % 84.4%

Unexplained % 15.6%

Explanatory variables E C E (Neumark^a) Proportion explained (%)

Age group 0.001 -0.178 0.001 5.44

Sex 0.000 -0.026 0.001 9.69

Geographic location 0.003 -0.003 0.003 19.88

Car ownership 0.001 0.012 0.001 9.75

Last dental visit -0.005 0.050 -0.006 0

Experience of racism 0.012 0.140 0.020 **55.25

Total 0.019 0.016 0.020 100

Notes

**p-value<0.01

*p-value<0.05.

aCoefficients obtained from the pooled data regression [14]. The coefficients were obtained from the pooled data regression. E (and E Neumark), C and CE show the contribution attributable to the gaps in endowments (E), the coefficients (C) and due to the interaction (CE). In this study, the gap in endowments accounts for the greatest bulk of the gap in outcomes. Proportion explained: related to change in endowments, attributable to experience of negative life events changes in the magnitude of the explanatory variables.

Unexplained: related to change in coefficients.

(8)

observed, were not accounted for in the analysis. In conclusion, our study provides new evi- dence on the magnitude of oral health inequities experienced by Indigenous Australians with differing exposure to negative life events, and the contributions of modifiable risk factors including experiences of racism. A deeper understanding of the insidious and pervasive nature of negative life events for Indigenous Australians, and efforts by policy makers and all health professionals are required to reduce preventable oral health inequities. This would go some way to addressing key priority areas as outlined in the 2015–2024 National Oral Health Plan [24].

Acknowledgments

We thank the study participants, Indigenous Reference Group, staff who collected data and key participating Aboriginal Community Controlled Health Organisations.

Author Contributions

Conceptualization: Lisa Jamieson, Joanne Hedges, Yin Paradies.

Data curation: Xiangqun Ju.

Formal analysis: Xiangqun Ju.

Funding acquisition: Lisa Jamieson.

Methodology: Yin Paradies, Xiangqun Ju.

Supervision: Lisa Jamieson.

Writing – original draft: Lisa Jamieson.

Writing – review & editing: Joanne Hedges, Yin Paradies, Xiangqun Ju.

References

1. Australian Bureau of Statistics. Australian Aboriginal and Torres Strait Islander Health Survey, 2019.

Canberra, ABS, 2020.

2. Australian Institute of Health and Wellbeing. Australian Burden of Disease Study 2018: key findings for Aboriginal and Torres Strait Islander people. Canberra, AIHW, 2021.

3. Australian Institute of Health and Wellbeing. Overweight and Obesity. Canberra, AIHW, 2020.

4. National Indigenous Australians Agency. National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017–2023. Canberra, NIAA, 2017.

5. Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Social Survey, 2014–15.

Canberra, ABS, 2016.

6. Dudgeon P, Blustein S, Bray A, Calma T, McPhee R, Ring I. Connection between family, kinship and social and emotional wellbeing. Canberra, AIHW, 2021.

7. Jamieson L, Do L, Kapellas K, Chrisopoulos S, Luzzi L, Brennan D, et al. Oral health changes among Indigenous and non-Indigenous Australians: findings from two national oral health surveys. Aust Dent J.

2021;S48–S55.https://doi.org/10.1111/adj.12849PMID:33899961

8. Slade G, Spencer AJ, Roberts-Thomson KR. Australia’s Dental Generations: the National Survey of Adult Oral Health 2004–06. Canberra, AIHW, 2007.

9. Krichauff S, Hedges J, Jamieson L. ’There’s a Wall There-And That Wall Is Higher from Our Side’:

Drawing on Qualitative Interviews to Improve Indigenous Australians’ Experiences of Dental Health Ser- vices. Int J Environ Res Public Health. 2020; 17:6496.https://doi.org/10.3390/ijerph17186496PMID:

32906607

10. Jamieson LM, Garvey G, Hedges J, Leane C, Hill I, Brown A, et al. Cohort profile: indigenous human papillomavirus and oropharyngeal squamous cell carcinoma study—a prospective longitudinal cohort.

BMJ Open. 2021; 11:e046928.https://doi.org/10.1136/bmjopen-2020-046928PMID:34083343

(9)

11. Kowal E, Gunthorpe W, Bailie RS. Measuring emotional and social wellbeing in Aboriginal and Torres Strait Islander populations: an analysis of a Negative Life Events Scale. Int J Equity Health. 2007; 6:18.

https://doi.org/10.1186/1475-9276-6-18PMID:18001479

12. Paradies YC, Cunningham J. Development and validation of the measure of indigenous racism experiences (MIRE). Int J Equity Health. 2008; 7:9.https://doi.org/10.1186/1475-9276-7-9PMID:18426602 13. Rahimi E, Hashemi Nazari SS. A detailed explanation and graphical representation of the Blinder-

Oaxaca decomposition methods with its application in health inequalities. Emerg Themes Epidemiol.

2021; 18:12.

14. Neumark D. Employers’ discriminatory behaviour and the estimation of wage discrimination. J Hum Resour. 1988; 23:279–295.

15. Markwick A, Ansari Z, Clinch D, McNeil J. Experiences of racism among Aboriginal and Torres Strait Islander adults living in the Australian state of Victoria: a cross-sectional population-based study. BMC Public Health. 2019; 19:309.https://doi.org/10.1186/s12889-019-6614-7PMID:30871531

16. Diversity Council Australia. Gari Yala (Speak the Truth): Centreing the Work Experiences of Aboriginal and/or Torres Strait Islander Australians. Sydney , Diversity Council Australia/Jumbunna Institute, 2020.

17. Brennan DS, Luzzi L, Chrisopoulos S, Haag DG. Oral health impacts among Australian adults in the National Study of Adult Oral Health (NSAOH) 2017–18. Aust Dent J. 2020; 65:S59–S66.https://doi.org/

10.1111/adj.12766PMID:32583589

18. Chand R, Parker E, Jamieson L. Differences in, and Frames of Reference of, Indigenous Australians’

Self-rated General and Oral Health. J Health Care Poor Underserved. 2017; 28:1087–1103.https://doi.

org/10.1353/hpu.2017.0099PMID:28804080

19. Collins E, Hearn T, Satur J. Consulting a Victorian Aboriginal community about their oral health. Aust J Rural Health. 2022 Jun 28.https://doi.org/10.1111/ajr.12898PMID:35763446

20. Poirier B, Hedges J, Jamieson L. Walking together: Relational Yarning as a mechanism to ensure meaningful and ethical Indigenous oral health research in Australia. Aust N Z J Public Health. 2022;

46:354–360.https://doi.org/10.1111/1753-6405.13234PMID:35357721

21. National Health & Medical Research Council. Road Map 3: A strategic framework for improving Aborigi- nal and Torres Strait Islander health through research. Canberra, NHMRC, 2018.

22. Milligan E, West R, Saunders V, Bialocerkowski A, Creedy D, Rowe Minniss F, et al. Achieving cultural safety for Australia’s First Peoples: a review of the Australian Health Practitioner Regulation Agency- registered health practitioners’ Codes of Conduct and Codes of Ethics. Aust Health Rev. 2021; 45:398–

406.https://doi.org/10.1071/AH20215PMID:33844959

23. Smith PD, Evans CA, Fleming E, Mays KA, Rouse LE, Sinkford J. Establishing an antiracism framework for dental education through critical assessment of accreditation standards. J Dent Educ. 2022;

86:1063–1074.https://doi.org/10.1002/jdd.13078PMID:36165256

24. Australian Health Ministers Advisory Council. Healthy Mouths, Healthy Lives: Australia’s National Oral Health Plan 2015–2024. Canberra, AHMAC, 2015.